Remarkable gains have been made over that last century in the safety of anesthesia and surgical procedures performed in operating rooms. Despite these improvements, intra-operative emergencies like cardiac arrest and massive hemorrhage do occur. The infrequency of these emergencies, while fortunate, challenges operating teams to work at their highest levels in situations that they rarely encounter. Particularly under stress, human memory is imperfect and response to crises can be compromised by the omission of key steps or failure to consider critical possibilities, resulting i threats to patient safety and potential tragedy. Previous research, including AHRQ-funded work, has recently demonstrated that the use of crisis checklists and emergency manuals can dramatically improve team performance. Crisis checklists and emergency manuals with appropriate training in their use can provide critical direction during a crisis. There has been increasing effort in recent years to raise awareness and encourage the implementation of operating room crisis checklists and emergency manuals throughout the country. Tens of thousands of clinicians and their institutions have become aware of these tools and thousands have downloaded versions from websites. Some of these adopters have gone on to implement the tools in their operating rooms with varying degrees of success. The aim of this project is to understand the current efforts that have gone into the implementation of crisis checklists/emergency manuals in order to discover unique practices and approaches that will lead to the creation of an innovative toolkit to help others implement more easily and effectively. Through the process of encouraging adoption and implementation of these tools widely, we have assembled a database of contacts of engaged institutions and clinicians. This database provides a window into implementation efforts nationally and is unique in nature and size. Many institutions will have struggled in their efforts to put these tools into place. Many will have discovered the difficulty of training experienced practitioners to change practice and integrate the use of these tools in a crisis situation, when they had previously relied solely on memory. Some institutions will find particularly effective ways of working around these problems. Through the use of a mixed methods approach utilizing surveys and subsequent targeted interviews, we will generate new ideas, analyze implementation efforts, address critical barriers and synthesize this information into an actionable form, an implementation toolkit. This toolkit can help those who have failed and those who have yet to begin. The knowledge generated here will also benefit implementation of similar checklists in clinical settings outside of the operating room. Aspects of the lessons harvested from this research will be generalizable to efforts to implement other innovations in health care and narrow the gap between institutional adoption and effective clinical use. The project is aligned with the mission of AHRQ to improve patient safety and the quality of health care and will draw on the TeamSTEPPS program.